Detail Cantuman

ANALISIS KUALITATIF BERKAS REKAM MEDIS RAWAT INAP PASIEN DEWASA DHF (Dengue Haemorrhagic Fever) RSI FATIMAH BANYUWANGI PERIODE TRIWULAN IV TAHUN 2016 (Qualitative Analysis Of Medical Record File Inpatient Adult Patients DHF (Dengue Haemorrhagic Fever) RSI Fatimah Banyuwangi Quarter IV Year 2016)
Elsa Yanuarti Diminar
Study Program of Medical Record
Majoring of Health
ABSTRACT
Qualitative analysis is the examination of (inconsistent), inaccuracies/information recorded health care personnel. This type of research is qualitative. The subject i.e. 1 doctor, 1 nurse and 1 head of medical record. The research object of 26 adult patients file DHF (Dengue Haemorrhagic Fever) quarter IV year 2016. The variables used are variable AKLA (Administrative Qualitative Analysis) and AKMED (medical qualitative analysis). Based on the results of the study found the gap from observations with the SOP. The variable clarity issues and the condition/diagnosis, 19% fever but no description of the giving of the antipyretic (medicine antrain), 15% there is no description of the sign of bleeding, but there is a description of the drug. Variables enter consistent 8% without the caption data but there is feverish body temperature fever, 12% categorized data and features shock shock, tombositopenia and 81% 19% of normal platelets. 100% service reason variable administering intravenous fluids RL/RA doesn't match IE 7-8jam and 8% of patients platelets 20,000 mm3 cannot < note transfusion of platelets. The variable identity Informed Consent 77% and 4% are not filled, the information of the medical Act 62% complete unfilled & 77% the authentication credentials are not full filled. Variable record 65% study writing is difficult to read. Variable anamnesa 12% without long description fever, 100% no tourniquet test result. Variable 43% therapy is not appropriate. The variable condition of the patients returned 19% fever does not go down, and 73% of platelets is not back to normal. Advice that the qualitative analysis done needs to be done, namely assessing the completeness of the file as it appears on the charging procedure anyway. Necessary additions/improvements at a fixed procedure. Give a reprimand and appreciation to medical personnel associated with the filling of the medical record to be more disciplined in charge and can add to the spirit in work that makes the performance of the officer's full potential.
Keyword : Qualitative, AKLA, AKMED



ANALISIS KUALITATIF BERKAS REKAM MEDIS RAWAT INAP PASIEN DEWASA DHF (Dengue Haemorrhagic Fever) RSI FATIMAH BANYUWANGI PERIODE TRIWULAN IV TAHUN 2016 (Qualitative Analysis Of Medical Record File Inpatient Adult Patients DHF (Dengue Haemorrhagic Fever) RSI Fatimah Banyuwangi Quarter IV Year 2016)
Elsa Yanuarti Diminar
Program Studi Rekam Medik
Jurusan Kesehatan
ABSTRAK
Analisis kualitatif adalah pemeriksaan tentang ketidakajegan (inconsistent), ketidakakuratan/informasi yang direkam tenaga kesehatan. Jenis penelitian adalah kualitatif. Subjek penelitian yaitu 1 dokter,1 perawat dan 1 kepala rekam medis. Obyek penelitian 26 berkas pasien dewasa DHF (Dengue Haemorrhagic Fever) periode triwulan IV tahun 2016. Variabel yang digunakan adalah variabel AKLA (Analisis Kualitataif Administratif) dan AKMED (Analisis Kualitataif Medis). Berdasarkan hasil penelitian ditemukan kesenjangan dari hasil observasi dengan SOP. Variabel kejelasan masalah dan kondisi/diagnosis, 58% tidak demam namun ada keterangan pemberian antipiretik (antrain), 15% tidak ada keterangan tanda perdarahan, namun ada keterangan pemberian obat. Variabel masukkan konsisten 100% terdapat data suhu tubuh 15% syok dan dilengkapi data syok, 81% tombositopenia dan 19% trombosit normal. Variabel alasan pelayanan 100% pemberian cairan intravena RL/RA tidak sesuai yaitu 7-8jam dan 4% pasien trombosit <20.000 mm3 tidak dapat catatan transfusi trombosit. Variabel Informed Consent identitas 77% tidak lengkap dan 4% tidak diisi, informasi tindakan medis 62% tidak terisi lengkap & autentifikasi 77% tidak terisi lengkap. Variabel telaah rekaman 65% tulisan sulit dibaca. Variabel anamnesa 8% tanpa keterangan lama demam, 100% tidak ada hasil uji tourniquet. Variabel terapi non farmakologis 43% tidak sesuai, farmakologis 58% kondisi tidak demam diberikan obat antipiretik. Variabel kondisi pasien pulang 15% demam tidak turun dan 73% trombosit tidak kembali normal. Saran yaitu perlu dilakukan penambahan/perbaikan pada prosedur tetap/SOP.
Kata kunci: Kualitatif, AKLA, AKMED